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psnet.ahrq.gov/issue/patient-who-falls-its-always-trade
February 17, 2011 - Commentary
The patient who falls: "It's always a trade-off."
Citation Text:
Tinetti ME, Kumar C. The patient who falls: "It's always a trade-off". JAMA. 2010;303(3):258-66. doi:10.1001/jama.2009.2024.
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psnet.ahrq.gov/issue/paediatric-nurses-understanding-process-and-procedure-double-checking-medications
May 03, 2023 - Study
Paediatric nurses' understanding of the process and procedure of double-checking medications.
Citation Text:
Dickinson A, McCall E, Twomey B, et al. Paediatric nurses' understanding of the process and procedure of double-checking medications. J Clin Nurs. 2010;19(5-6). doi:10.111…
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psnet.ahrq.gov/issue/alarm-fatigue-impacts-patient-safety
December 02, 2020 - Review
Alarm fatigue: impacts on patient safety.
Citation Text:
Ruskin KJ, Hueske-Kraus D. Alarm fatigue: impacts on patient safety. Curr Opin Anaesthesiol. 2015;28(6):685-690. doi:10.1097/ACO.0000000000000260.
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psnet.ahrq.gov/issue/strategies-safe-medication-use-ambulatory-care-settings-united-states
March 08, 2017 - Study
Strategies for safe medication use in ambulatory care settings in the United States.
Citation Text:
Sorensen AV, Bernard SL. Strategies for Safe Medication Use in Ambulatory Care Settings in the United States. J Patient Saf. 2009;5(3). doi:10.1097/pts.0b013e3181b3afc1.
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psnet.ahrq.gov/issue/reducing-interdisciplinary-communication-failures-through-secure-text-messaging-quality
May 08, 2017 - Study
Reducing interdisciplinary communication failures through secure text messaging: a quality improvement project.
Citation Text:
Hansen JE, Lazow M, Hagedorn PA. Reducing Interdisciplinary Communication Failures Through Secure Text Messaging. Pediatr Qual Saf. 2019;3(1). doi:10.1097/…
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psnet.ahrq.gov/issue/diagnostic-time-outs-improve-diagnosis
September 14, 2022 - Study
Diagnostic time-outs to improve diagnosis.
Citation Text:
Yale S, Cohen S, Bordini BJ. Diagnostic time-outs to improve diagnosis. Crit Care Clin. 2022;38(2):185-194. doi:10.1016/j.ccc.2021.11.008.
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psnet.ahrq.gov/issue/systematic-review-human-factors-and-ergonomics-hfe-based-healthcare-system-redesign-quality
February 13, 2014 - Review
A systematic review of human factors and ergonomics (HFE)-based healthcare system redesign for quality of care and patient safety.
Citation Text:
Xie A, Carayon P. A systematic review of human factors and ergonomics (HFE)-based healthcare system redesign for quality of care and pa…
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psnet.ahrq.gov/issue/organizational-culture-critical-success-factors-and-reduction-hospital-errors
December 12, 2014 - Study
Organizational culture, critical success factors, and the reduction of hospital errors.
Citation Text:
Stock GN, McFadden KL, Gowen CR. Organizational culture, critical success factors, and the reduction of hospital errors. Int J Prod Econ. 2006;106(2). doi:10.1016/j.ijpe.2006.0…
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psnet.ahrq.gov/issue/effect-pharmacists-medication-errors-emergency-department
September 23, 2020 - Study
Effect of pharmacists on medication errors in an emergency department.
Citation Text:
Brown JN, Barnes CL, Beasley B, et al. Effect of pharmacists on medication errors in an emergency department. Am J Health Syst Pharm. 2008;65(4):330-3. doi:10.2146/ajhp070391.
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psnet.ahrq.gov/issue/wakewings-journey-creating-patient-safety-program
September 23, 2020 - Commentary
The WakeWings journey: creating a patient safety program.
Citation Text:
Mills E. The WakeWings Journey: Creating a Patient Safety Program. AORN J. 2016;103(6):636-9. doi:10.1016/j.aorn.2016.04.004.
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psnet.ahrq.gov/issue/why-your-doctors-white-coat-can-be-threat-your-health
November 18, 2016 - Newspaper/Magazine Article
Why your doctor's white coat can be a threat to your health.
Citation Text:
Haun N, Hooper-Lane C, Safdar N. Healthcare Personnel Attire and Devices as Fomites: A Systematic Review. Infect Control Hosp Epidemiol. 2016;37(11):1367-1373.
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psnet.ahrq.gov/issue/reducing-disruptive-effects-interruption-cognitive-framework-analysing-costs-and-benefits
September 11, 2013 - Commentary
Reducing the disruptive effects of interruption: a cognitive framework for analysing the costs and benefits of intervention strategies.
Citation Text:
Boehm-Davis DA, Remington R. Reducing the disruptive effects of interruption: a cognitive framework for analysing the costs an…
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psnet.ahrq.gov/issue/fda-preliminary-public-health-notification-unpredictable-events-medical-equipment-due-new
June 02, 2021 - Government Resource
FDA preliminary public health notification: unpredictable events in medical equipment due to new daylight savings time change.
Citation Text:
FDA preliminary public health notification: unpredictable events in medical equipment due to new daylight savings time chang…
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psnet.ahrq.gov/issue/direct-oral-anticoagulants-new-drugs-practical-problems-how-can-nurses-help-prevent-patient
November 16, 2022 - Commentary
Direct oral anticoagulants: new drugs with practical problems. How can nurses help prevent patient harm?
Citation Text:
Barras MA, Hughes D, Ullner M. Direct oral anticoagulants: New drugs with practical problems. How can nurses help prevent patient harm? Nurs Health Sci. 2016…
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psnet.ahrq.gov/issue/patient-safety-and-quality-care
April 01, 2020 - Commentary
Patient safety and quality care.
Citation Text:
Nelson K. Patient safety and quality care. Clin Dermatol. 2014;32(4):542-4. doi:10.1016/j.clindermatol.2013.12.001.
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psnet.ahrq.gov/issue/safety-culture-includes-good-catches
August 21, 2024 - Commentary
Safety culture includes "good catches."
Citation Text:
Traynor K. Safety culture includes "good catches". Am J Health Syst Pharm. 2015;72(19):1597-1599. doi:10.2146/news150065.
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psnet.ahrq.gov/node/848107/psn-pdf
April 26, 2023 - Improving Diagnostic Safety and Quality
April 26, 2023
Al-Khafaji J, Lee M, Mossburg S. Improving Diagnostic Safety and Quality . PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality
Introduction
During an annual editorial review of featured articles in the Agency for …
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psnet.ahrq.gov/innovations
February 26, 2025 - Innovations
The PSNet Innovations page highlights pioneering advances that can improve patient safety. PSNet innovations are defined as “new or updated interventions, approaches, systems, tools, policies, organizational structures or business models implemented to improve or enhance quality of care and reduce harm.” …
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psnet.ahrq.gov/primer/covid-19-team-and-human-factors-improve-safety
September 15, 2024 - COVID-19: Team and Human Factors to Improve Safety
Citation Text:
Zipperer L. COVID-19: Team and Human Factors to Improve Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/primer/deprescribing-patient-safety-strategy
December 15, 2024 - Deprescribing as a Patient Safety Strategy
Citation Text:
Takhar S, Nelson N. Deprescribing as a Patient Safety Strategy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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